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Pergola V, Continisio S, Mantovani F, Motta R, Mattesi G, Marrazzo G, Dellino CM, Montonati C, De Conti G, Galzerano D, Parato VM, Gimelli A, Barchitta A, Campana M, D'Andrea A. Spontaneous coronary artery dissection: the emerging role of coronary computed tomography. Eur Heart J Cardiovasc Imaging 2023:7135507. [PMID: 37082977 DOI: 10.1093/ehjci/jead060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/12/2023] [Indexed: 04/22/2023] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome and myocardial infarction, more frequent among young women. Invasive coronary angiography (ICA) is the gold standard for the diagnosis of SCAD, although the risk of propagating dissection flap is considerable. Therefore, coronary computed tomography angiography (CCTA) is an emerging alternative modality to diagnose SCAD with the advantage of being a non-invasive technique. Clinicians should be aware of the predisposing conditions and pathophysiology to raise the pre-test probability of SCAD and select the most appropriate diagnostic tools. In recent times, improvements in spatial and temporal resolution and the use of semi-automated software providing quantitative assessment make CCTA a valid alternative to ICA also for the follow-up. Moreover, CCTA may be helpful to screen and evaluate extra-coronary arteriopathies closely related to SCAD. In this review, we illustrate the current and the potential role of CCTA in the diagnosis of SCAD, highlighting advantages and disadvantages of this imaging modality compared to ICA.
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Affiliation(s)
- Valeria Pergola
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Saverio Continisio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Francesca Mantovani
- Department of Cardiology, Azienda USL, IRCCS di Reggio Emilia, Via Giovanni Amendola, 2, 42122 Reggio Emilia, Italy
| | - Raffaella Motta
- Unit of Radiology, Department of Medicine, Medical School, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Giulia Mattesi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Gemma Marrazzo
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Via Alfonso de Nicola, 84014, Nocera Inferiore, Italy
| | - Carlo Maria Dellino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Carolina Montonati
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Giorgio De Conti
- Unit of Radiology, Department of Medicine, Medical School, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Domenico Galzerano
- Cardiac Centre, King Faisal Specialist Hospital and Research Centre, Al Mathar Ash Shamali, 11564 Riyadh, Saudi Arabia
| | - Vito Maurizio Parato
- Cardiology Unit, Emergency Dept, Hospital "Madonna del Soccorso", Via Luciano Manara, 8, 63074 San Benedetto del Tronto, Italy
| | - Alessia Gimelli
- Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124 Pisa, Italy
| | - Agatella Barchitta
- Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Marco Campana
- U.O.C. Cardiologia, Fondazione Poliambulanza, Via Don Pinzoni, 1, 25124 Brescia, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Via Alfonso de Nicola, 84014, Nocera Inferiore, Italy
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Bocchino PP, Franchin L, Angelini F, D'Ascenzo F, De Ferrari GM, Alfonso F. Outcomes during the first year following spontaneous coronary artery dissection: A systematic timeframe pooled analysis. Catheter Cardiovasc Interv 2021; 99:472-479. [PMID: 34773431 DOI: 10.1002/ccd.30016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/11/2021] [Accepted: 10/27/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We aimed to compare the incidence and timing of major adverse cardiovascular events (MACE) within the first year after spontaneous coronary artery dissection (SCAD) according to the management strategy: conservative versus invasive. BACKGROUND Treatment of SCAD remains controversial. METHODS A pooled analysis of studies providing separate individual clinical outcomes for conservative and invasive treatment strategies within 1 year after SCAD was performed. The primary outcome measure was MACE incidence within three predefined study periods after SCAD, namely "in-hospital", "discharge-to-6-months" and "6-to-12-months". MACE was defined as a composite of all-cause death, myocardial infarction, target vessel revascularization, heart failure and SCAD recurrence. RESULTS A total of 16 studies (444 patients) were included; 277 (62%) patients were treated conservatively and 167 (38%) invasively. Within 1-year follow-up, 39 (67%) MACE occurred during the in-hospital period compared to 10 (17%) in the "discharge-to-6 months" period and 9 (16%) in the "6-to-12-months" period (p < 0.0001 for the overall comparison). MACE incidence was also significantly different between the three study periods in the conservatively-treated group (23 [78%] vs. 7 [23%] vs. 0 [0%], respectively; p < 0.0001) and the invasively-treated group (12 [66%] vs. 3 [17%] vs. 3 [17%], respectively; p < 0.0001), although no significant difference was found regarding MACE incidence in the intra-period comparisons between conservative and invasive treatment strategies. CONCLUSIONS This pooled analysis showed that most MACE following SCAD occurred during the in-hospital period compared to the following two semesters, regardless of the treatment strategy. No difference regarding MACE incidence was found between conservative and invasive strategies in each study period.
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Affiliation(s)
- Pier Paolo Bocchino
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Luca Franchin
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBER-CV, Madrid, Spain
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Bocchino PP, Angelini F, Franchin L, D'Ascenzo F, Fortuni F, De Filippo O, Conrotto F, Alfonso F, Saw J, Escaned J, Liu C, De Ferrari GM. Invasive versus conservative management in spontaneous coronary artery dissection: A meta-analysis and meta-regression study. Hellenic J Cardiol 2021; 62:297-303. [PMID: 33689856 DOI: 10.1016/j.hjc.2021.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/02/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Data regarding the best treatment for spontaneous coronary artery dissection (SCAD) are limited. The aim of the present study was to compare the clinical outcomes of conservative versus invasive treatment in SCAD patients. METHODS We systematically searched the literature for studies evaluating the comparative efficacy and safety of invasive revascularization versus medical therapy for the treatment of SCAD from 1990 to 2020. The study endpoints were all-cause death, cardiovascular death, myocardial infarction, heart failure, SCAD recurrence and target vessel revascularization (TVR) rates. Random effect meta-analysis was performed by comparing the clinical outcomes between the two groups. A univariate meta-regression analysis was also performed. RESULTS Twenty-four observational studies with 1720 patients were included. After 28 ± 14 months, a conservative approach was associated with lower TVR rate compared with invasive treatment (OR = 0.50; 95%CI 0.28-0.90; P = 0.02). No statistical difference was found regarding all-cause death (OR = 0.81; 95%CI 0.31-2.08; P = 0.66), cardiovascular death (OR = 0.89; 95%CI 0.15-5.40; P = 0.89), myocardial infarction (OR = 0.95; 95%CI 0.50-1.81; P = 0.87), heart failure (OR 0.96; 95%CI 0.41-2.22; P = 0.92) and SCAD recurrence (OR = 0.94; 95%CI 0.52-1.72; P = 0.85). The meta-regression analysis suggested that male gender, diabetes mellitus, smoking habit, prior coronary artery disease, left main coronary artery involvement, lower ejection fraction and low TIMI flow at admission were related with high overall mortality, whereas SCAD recurrence was higher among patients with fibromuscular dysplasia. CONCLUSIONS A conservative approach was associated with similar clinical outcomes and lower TVR rates compared with an invasive strategy in SCAD patients; future prospective studies are needed to confirm these results.
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Affiliation(s)
- Pier Paolo Bocchino
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy.
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Luca Franchin
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Federico Fortuni
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, Universidad Autónoma de Madrid, CIBER-CV, Madrid, Spain
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Javier Escaned
- Unidad de Cardiología Intervencionista, Hospital Clínico San Carlos, Madrid, Spain
| | - Chengwei Liu
- Department of Cardiology, Wuhan Asia Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, University of Turin, "Città della Salute e della Scienza" Hospital, Turin, Italy
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Abstract
Introduction: Spontaneous coronary artery dissection (SCAD) is a cause of non-atherosclerotic acute coronary syndrome and sudden cardiac death that predominantly impacts young and middle-aged women. In addition to the challenges of acute SCAD including arrhythmias, heart failure, and recurrent chest pain, de novo recurrent SCAD occurs in 5-29% of patients. Recurrent SCAD presents both a psychological burden and a significant cardiac risk to patients. Research regarding SCAD recurrence risk has been growing and can guide providers and patients alike.Areas covered: This review provides up-to-date information about many aspects of SCAD with a focus on SCAD recurrence. PubMed articles were reviewed through October 2020, with particular focus on clinical studies and original research. The resulting literature was scrutinized for information on SCAD recurrence. SCAD-associated conditions, genetic data, clinical characteristics, medications, and aspects of post-SCAD care are summarized.Expert Opinion: SCAD recurrence poses a concerning risk for patients with SCAD. Conditions such as hypertension and severe coronary tortuosity may be associated with recurrence. More research is needed to further elucidate risk factors for recurrence and clarify interventions, such as beta blocker therapy, that may reduce recurrence risk.
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Affiliation(s)
- Susan N Kok
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Marysia S Tweet
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Systematic review and meta-analysis of the incidence of recurrence of spontaneous coronary artery dissection. Coron Artery Dis 2021; 32:650-657. [PMID: 33471472 DOI: 10.1097/mca.0000000000001015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Recurrence is a well-established complication of spontaneous coronary artery dissection (SCAD). However, the exact incidence and correlates of recurrence are unknown. We, therefore, performed a systematic review and meta-analysis to determine and consolidate the evidence on the global incidence of SCAD recurrence. METHODS A comprehensive search of the four major databases (EMBASE, OVID Medline, PubMed and Google Scholar) was performed from their inception to 17 January 2019. We included original research studies, recruiting ≥10 participants, with ≥12 months follow-up that reported data on recurrence in patients with SCAD. RESULTS Out of 556 studies searched, 19 cohorts (1538 SCAD patients) were included in the analysis. There were 153 cases of de novo recurrence over a mean follow-up period of 31.2 months (95% confidence interval, 25-41 months). Type 1, 2 and 3 SCAD was noted in 33.2, 73.2 and 5.3%, respectively. The involved coronary artery was left anterior descending artery, left anterior descending artery, right coronary artery, left circumflex artery and multivessel coronary artery disease, respectively, in 3.5, 53.4, 19.8, 20.4 and 12.6% of cases. The overall SCAD de novo recurrence was 7% (ES 0.07, 95% confidence interval, 0.04-0.10, I2 = 65.3%). On meta-regression, we found discharge medications at index admission, including β-blockers, ACE inhibitors, statins, as well as baseline cardiac risk factors, did not correlate with recurrence. CONCLUSION SCAD recurrence is common, occurring in 7% of patients over medium-term follow up. No specific medications at discharge were found to reduce recurrence. Further long-term and prospective data are required.
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Macaya F, Vedia Ó, Salazar CH, Mejía-Rentería H, Ruiz-Pizarro V, Salinas P, Gonzalo N, Pérez-Vizcayno MJ, Vilacosta I, Fernández-Ortiz A, Macaya C, Escaned J, Núñez-Gil IJ. Clinical outcomes of patients presenting with spontaneous coronary artery dissection versus takotsubo syndrome: a propensity score analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:694-702. [DOI: 10.1177/2048872619886311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background:
Spontaneous coronary artery dissection and takotsubo syndrome are non-atherosclerotic causes of acute coronary syndromes. They share clinical features including female predominance and frequent triggers. We compared the outcomes of patients with spontaneous coronary artery dissection and patients with takotsubo syndrome with similar clinical characteristics.
Methods:
Patients with spontaneous coronary artery dissection (n=81) or takotsubo syndrome (n=341) were 1:1 propensity matched according to age, sex, cardiovascular risk factors and clinical presentation. We compared baseline characteristics, effects on left ventricular function, and recurrence of major adverse cardiovascular events; defined as a composite of new hospitalisation for cardiac cause, clinical recurrence (spontaneous coronary artery dissection/takotsubo syndrome), myocardial infarction and death.
Results:
Propensity score yielded 78 pairs: 85% were women, whose average age was 55.3±12.6 years, 28% had two or more cardiovascular risk factors, 37% presented with ST-segment elevation and 5% presented with cardiogenic shock. In the spontaneous coronary artery dissection group, 50% (39/78) of cases involved the left anterior descending artery and 18% (14/78) underwent revascularisation. After a median follow-up of 5 years (interquartile range 2.4–5), major adverse cardiovascular events were significantly higher in the spontaneous coronary artery dissection group (18% (14/78) vs. 8% (6/78); hazard ratio 3.40, 95% confidence interval 1.2–9.4). This was mainly driven by early readmissions for cardiac causes (17% vs. 5%, P=0.007). Spontaneous coronary artery dissection was associated with higher peak values of creatinine kinase during admission (creatinine kinase/upper limit of normality 2.49 vs. 1.21, P<0.001). Binary left ventricular systolic dysfunction was more prevalent in the takotsubo syndrome group (22% vs. 53%, P<0.001), but no significant differences were noted at follow-up (6% vs. 1%, P=0.181).
Conclusions:
In this cohort of middle-aged predominantly female patients presenting with acute coronary syndromes, the diagnosis of spontaneous coronary artery dissection compared to takotsubo syndrome conferred a worse long-term clinical outcome, mainly driven by an increased risk of rehospitalisation for cardiac causes.
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Mori R, Macaya F, Sara JD, Toya T, Mejía-Rentería H, Gonzalo N, Lerman A, Escaned J. Non-invasive assessment of endothelial function in patients with spontaneous coronary artery dissection: A case-control study. Int J Cardiol 2020; 316:40-42. [DOI: 10.1016/j.ijcard.2020.04.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/09/2020] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
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Cerrato E, Giacobbe F, Rolfo C, Quadri G, Tomassini F, Ferrari F, Mariani F, Anselmino M, Bianco M, Belliggiano D, Savio LL, Franzé A, Barbero U, Porto I, Mejía-Rentería H, Macaya F, Salinas P, Gonzalo N, Escaned J, Montagna L, Varbella F. Role of Invasive and Non-invasive Imaging Tools in the Diagnosis and Optimal Treatment of Patients with Spontaneous Coronary Artery Dissection. Curr Cardiol Rep 2019; 21:122. [DOI: 10.1007/s11886-019-1202-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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